This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fang, J. Articles by Tu, J. V. Search for Related Content PubMed PubMed Citation Articles by Fang, J. Articles by Tu, J. V. Pubmed/NCBI databases Medline Plus Health Information Stroke Related Collections Cerebrovascular disease/stroke Other Stroke Acute Cerebral Hemorrhage Acute Cerebral Infarction Primary and Secondary Stroke Prevention

(Stroke. 2001;32:2221.)
© 2001 American Heart Association, Inc.

Original Contributions

Trend of Stroke Hospitalization, United States, 1988–1997

Jing Fang, MD Michael H. Alderman, MD

From the Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, NY.

Reprint requests to Dr Jing Fang, Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461. E-mail fang{at}aecom.yu.edu

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References Are We Winning the... References

 
Background and Purpose—— Age-adjusted stroke mortality in the United States has declined in recent decades. However, the course of stroke incidence is less certain. To address this issue, we determined trends of stroke hospitalization and in-hospital case fatality during 1988–1997.

Methods—— Stroke hospitalization was estimated from National Hospital Discharge Survey as numerator and Current Population Survey as denominator. Hospitalization rates were determined and stratified by patient characteristics. Average length of hospital stay was also determined. In-hospital mortality was specified by sex, age, and other patient characteristics. The change in these rates over 10 years and average annual percent changes were calculated.

Results—— During 1988–1997, age-adjusted stroke hospitalization rate increased 18.6% (from 560 to 664/100 000; P=0.043), while total hospitalization increased from 592 811 to 821 760. This increase was limited to persons aged 65 years. Patients in the South had the highest stroke hospitalization rates, and those in the West had the lowest. Overall, 58% of strokes were classified as ischemic, 13% as hemorrhagic, and 29% as other. Over these 10 years, stroke patients having coincident diabetes, hypertension, and congestive heart failure increased 17.4% (P=0.17), 34% (P=0.05), and 31% (P=0.091), respectively. The average length of hospital stay fell from 11.1 to 6.2 days (44.1%; P=0.012). As a result, despite an increase in hospitalizations for stroke, the total person-days in hospital actually decreased by 22% (P=0.06).

Conclusions—— The declining age-adjusted stroke mortality in the United States has not been accompanied by a fall in hospitalization over recent years. Thus far, however, decrease in length of stay has more than offset increased admission. At the same time, the sharp drop in hospital case fatality rates suggests that continuing decline in stroke mortality may be due, in large part, to improved survival after acute stroke.

Key Words: health care surveys • hospitalization • hospital mortality • length of stay

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References Are We Winning the... References

 
Stroke is a major health problem. Not only is it the third leading cause of death in the United States, after heart disease and cancer,¹ but many stroke survivors are permanently disabled. US stroke mortality has declined dramatically in recent decades.^2,3 This may be a consequence of declining incidence, declining case fatality rate, or both. Few studies have used consistent methods for the country as a whole, or for sufficiently long periods of time, to accurately determine national trends in both incidence and case fatality. There have been no nationwide studies of stroke morbidity in the United States over the past decade.

Evidence from regional studies suggests that, since 1980, the incidence of stroke may no longer be declining and may even be increasing.^4–9 At the same time, studies around the world suggest that case fatality rates are declining.^10–13

To estimate the most recent hospitalization and in-hospital case fatality rates for stroke in the United States and to test the hypothesis of whether the decline of stroke mortality has mirrored the reduction of stroke incidence in the United States, we report rates of hospitalization for stroke and in-hospital mortality by sex, age, and region in the United

See Editorial Comment, page 2226

States during 1988–1997 based on the National Hospital Discharge Survey (NHDS).

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References Are We Winning the... References

 
Data Source
Data were obtained from the NHDS, conducted by the National Center for Health Statistics.^14–16 Since 1965 this survey has obtained a nationally representative sample of discharge records from nonfederal short-stay hospitals in the United States. The NHDS covers discharges from noninstitutional hospitals, not including federal, military, and Veterans Administration hospitals. Only short-stay hospitals (those with an average length of stay for all patients of <30 days) and those with a general specialty are included in the survey. These hospitals must also have 6 beds staffed for patient use. During 1988–1997, each year there were approximately 6200 to 6400 hospitals in the NHDS universe and approximately 513 to 542 hospitals in the NHDS sample. Each year approximately 200 000 patients’ records are abstracted and weighted to represent all such hospital discharges nationwide.

Information collected from hospital records included date of birth and sex of patient, admission and discharge dates, discharge status, up to 7 discharge diagnoses, up to 4 procedures performed during hospitalization, length of hospital stay, and region of residence. We have not provided estimates for racial and ethnic groups in this analysis because such classifications of NHDS data were incomplete and became increasingly so during this period. Underreporting of race or ethnicity increased from 10% in the 1985 survey to almost 20% in 1992.¹⁷

We defined patients with stroke by the principal diagnostic code of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) of 431 to 434 and 436 to 438. Among these patients, we also defined the comorbidity status for stroke by other ICD-9 codes (second to seventh diagnostic codes). These conditions included diabetes (ICD 250), hypertension (ICD 401 to 405), coronary heart disease (ICD 410 to 414), and congestive heart failure (ICD 428). We then categorized stroke into hemorrhagic stroke (ICD-9-CM 431 to 432) and ischemic stroke (ICD-9-CM 433 to 434 and 437.0 to 437.2). The detailed methods of design, data collection, ICD coding, and quality control have been reported.¹⁸

The patients of this study consisted of the sampled populations aged 35 years hospitalized during 1988–1997.

For computation of discharge rates, population estimates were taken from the census data, Current Population Survey (CPS). This survey is administered monthly each year by the US Bureau of the Census to >50 000 households through a sample design. By taking into account the sample weight, the sample can be representative of the US population.¹⁹ Each month’s survey has a different emphasis. The March survey used here contains the survey during 1988–1997 of the Annual Demographic File and the Income Supplement, which reports, in detail, the income-related aspects of US households.

Statistical Analysis
For both NHDS and CPS data, weighted variables were used to account for entire US population.

Using the 2000 US population as standard,²⁰ we computed age-adjusted stroke hospitalization rates for each year during 1988–1997. Age-adjusted rates for hemorrhagic and ischemic stroke were then estimated separately. Other comorbidity conditions, including congestive heart failure, diabetes, hypertension, and coronary heart disease, were determined from diagnostic codes other than the first one and were estimated as percentage of total stroke hospitalization. Hospitalization was further categorized by geographic region into Northeast, Midwest, South, and West. The definition for each region was the same as used by the Census Bureau²¹ and was applied for both hospital discharge data and CPS data. Age-adjusted stroke hospitalization rates for each region were computed. Average length of hospital stay and person-days in hospital were determined in each year. In-hospital case fatality rate was determined by the percentage of patients who died at discharge among all those hospitalized for stroke. This rate was estimated by age, sex, region, type of stroke, and morbidity status. Percent changes in case fatality rates were determined from 1988 to 1997. Average annual percent changes of the rates were estimated by the percent changes of rates for each year. One-sample t test was performed to test the difference from 0 for the average of changes for all study periods.

Age-adjusted stroke mortality rates during 1988–1997 were obtained from the National Center for Health Statistics.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References Are We Winning the... References

 
Overall, during these 10 years, the actual number of stroke hospitalizations increased from 592 811 in 1988 to 821 760 in 1997 (38.6%). At the same time, age-adjusted stroke mortality reported by the National Center for Health Statistics fell from 29.9 to 25.9 per 100 000 population (13.4%).

Stroke Hospitalization Rates
Overall, the age-adjusted stroke hospitalization rate increased from 560 per 100 000 population in 1988 to 664 in 1997 (18.6%; P=0.043). The average annual percent change was 2.15 (95% CI, 0.13 to 4.37; P=0.05).

Stroke hospitalization rates were 2650, 1085, and 180 per 100 000 population for those aged 75 years, 65 to 74 years, and <65 years, respectively. Men had higher stroke hospitalization rates than did women up to age 74 years. There was no significant sex-related difference for persons aged >75 years (Figure 1). During this time, stroke hospitalization rates did not change for men and women aged 35 to 64 years but increased for older men and women. This increase was greater for men than for women (Figure 1).

View larger version (25K): [in this window] [in a new window]   Figure 1. Stroke hospitalization by age and sex: NHDS data, 1988–1997.

By region of the United States, stroke hospitalization rates were lowest in the West and generally highest in the South. Although the stroke hospitalization rate in the West was generally 20% lower than other regions, the increase in the West was comparable to other parts of the country (Figure 2).

View larger version (19K): [in this window] [in a new window]   Figure 2. Age-adjusted stroke hospitalization by regions, United States, 1988–1997.

Length of Hospital Stay
The average length of hospital stay fell by 44.1% from 11.1 to 6.2 days from 1988 to 1997, with an average annual percent decrease of 6.1% (P=0.012). Therefore, although the actual number of patients hospitalized for stroke increased during this period, the total person-days in hospital decreased by 22% (P=0.06) (Figure 3).

View larger version (21K): [in this window] [in a new window]   Figure 3. Stroke hospital admission and total stroke person-days, United States, 1988–1997.

Type of Stroke
In 10 years, age-adjusted hospitalization rate for hemorrhagic stroke was 76.5 per 100 000 population in 1988 and 88.9 in 1997, increasing 16.2%. Average annual percent changes were 1.7 (P=0.57). Age-adjusted hospitalization rates for ischemic stroke were 296.2 in 1988 and 400.5 in 1997, increasing 35%. Average annual percent changes were 3.6 (P=0.03) (Figure 4).

View larger version (13K): [in this window] [in a new window]   Figure 4. Stroke hospitalization rate by type of stroke, 1988–1997.

Comorbidity
The comorbidity of diabetes among stroke patients increased by 17.4% from 19.3% to 22.6% (P=0.17), and that of hypertension increased by 33.6% from 39.3% to 52.5% (P=0.05) (Figure 5) during this period. However, while the percentage of patients with coronary heart disease remained constant over the 10 years (19.3% in 1988 and 19.4% in 1997), the percentage of patients with congestive heart failure, although small, increased by 31% from 6.4% to 8.4% (P=0.091) during this time (Figure 5).

View larger version (18K): [in this window] [in a new window]   Figure 5. Changes in percentage of stroke patients with other comorbidity. CHD indicates coronary heart disease; CHF, congestive heart failure; and HT, hypertension.

Hospital Discharge Status and Case Fatality Rate
During these 10 years, in-hospital death among stroke patients decreased steadily from 12.7% to 7.6% (40%; P=0.04). Discharge home was the outcome for most patients, and this fraction fell insignificantly from 57.6% to 53.9% (P=0.34). By approximately an equal amount, transfer to short- and long-term care facilities increased by 23% (from 6.5% to 8.0%; P=0.16) and 22% (from 16.2% to 19.7%; P=0.18), respectively (Figure 6).

View larger version (21K): [in this window] [in a new window]   Figure 6. Hospital discharge status, 1988–1997.

Stratification by age, sex, region, and type of stroke revealed an almost across-the-board decline in case fatality rates in 10 years (Table). Patients with hemorrhagic stroke had substantially higher in-hospital mortality than did patients with ischemic stroke. Older patients (75 years), men, and those hospitalized in the Northeast had higher in-hospital case fatality rates than did younger patients, women, and those hospitalized in other regions. During these 10 years, the decline of in-hospital case fatality rate varied substantially by patient characteristics. Specifically, in-hospital case fatality showed no consistent decline among patients aged <65 years, those with hemorrhagic stroke, and those living in the Midwest. On the other hand, patients aged 65 years and those who sustained an ischemic stroke had a much more favorable outcome (Table).

View this table: [in this window] [in a new window]   Table 1. Change in Case Fatality Rate From 1988 to 1997 Among Hospitalized Stroke Patients by Patients’ Characteristics: National Hospital Discharge Survey, 1988–1997

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References Are We Winning the... References

 
These findings give national context to recent suggestions that US stroke incidence may be increasing. Moreover, during these past 10 years, although both the total number and rates of stroke hospitalization increased, a dramatic fall in length of hospital stay has produced an actual decline in total stroke hospital days. At the same time, it is likely that the sharp drop observed in hospital case fatality rate, particularly in persons aged 65 years, has made an important contribution to the overall decline in national age-adjusted stroke mortality.

Worldwide experience suggests inconsistent patterns of incidence over the past several decades. In Sweden, for example, although mortality has fallen, it has not been possible to detect a parallel decline in stroke incidence. In fact, a significant rise in the incidence of acute stroke has also been seen among Swedish women during 1975–1978 and 1983–1986 compared with 1975–1978.⁹ In the United States, a study in Rochester, Minn, revealed an increase in stroke incidence. Age-adjusted incidence of acute stroke was 17% higher during 1980–1984 compared with 1975–1979, and this increase persisted during 1985–1989.⁶ Reviews of NHDS for 1979–1983 and 1970–1987 both reported a rise in the hospitalization for stroke.^7,8 By contrast, reductions in case fatality have been more consistent across regions and cultures. During 1955–1971, case fatality fell by approximately 30% in the United Kingdom.¹⁰ In Framingham, Mass, during 1958–1978, 1-year case fatality fell from 34% to 13% in men but not in women.¹¹ In the Minnesota Heart Study, 28-day case fatality halved during 1970–1985.^12,13

The finding of higher stroke hospitalization in the southern United States was consistent with the well-known southern "Stroke Belt." High stroke incidence and mortality rates were present in the Southeast for both blacks and whites.^22–24 By contrast, the West, in general, had a low stroke hospitalization rate, which was also consistent with earlier reports.²⁵

The increasing stroke hospitalization rate seen here, coupled with declining in-hospital mortality, suggests that the fall in overall national stroke mortality may largely be due to better treatment of stroke rather than improved prevention. Of course, it is not possible to be certain that increased hospitalization is a surrogate for increased stroke incidence. For example, the increased hospitalization seen here could be an artifact of changes in admission practices. Criteria for admission may have become more lenient, permitting entrance of patients with milder stroke. In addition, more frequent neuroimaging may have led to milder and equivocal stroke cases being confirmed and therefore admitted. If these changes did occur, the effect would have been to reduce case fatality rate by inflating the denominator. However, the consistent coincidence of coronary heart disease and, more significantly, the increasing incidence of congestive heart failure argue against this possibility. It is also possible that the ratio of hemorrhagic to ischemic stroke has declined, as observed here. This could result in reduced stroke mortality since ischemic stroke tends to have a better prognosis. On the other hand, since a previous stroke is a major risk factor for a subsequent stroke, and the largest increase of hospitalization was in older patients, the increasing admissions may be explained in part by improved survival after initial events.

The steady decline in days of hospital stay reflects a dramatic change in patterns of practice. Implementation of the Medicare prospective payment system stimulated a marked decline in length of hospital stay for stroke patients.²⁶ As a result, even in the face of increased total stroke hospitalization, the total number of hospital days for the nation decreased. At the same time, introduction of designated stroke units appears to have improved inpatient care.^27,28 The data here suggest that shorter hospitalization did not put patients at greater immediate risk; in fact, quite the opposite occurred. It is, of course, possible that posthospital death may have increased,²⁹ but this seems unlikely in view of overall decline in national stroke mortality.

The data here do not necessarily augur well for the future. The factors that have thus far contained hospital use by stroke patients may not be sustainable. There must be a limit to the ability to reduce length of stay. If recent trends for persons aged >75 years persist, an aging US population will, in the near future, probably increase consumption of medical resources by stroke patients.

The importance of hypertension, coronary artery disease, and diabetes, both as risk factors for stroke and as determinants of outcome, is well established and is reflected in these data. Interestingly, and somewhat paradoxically, stroke patients with each of these conditions tended to have a lower case fatality rate than those without. Perhaps the presence of these diagnoses signified more widespread participation in the medical care system and thus access to specific or nonspecific therapies that decreased the lethality of stroke. The impact of prior antihypertensive therapy on survival during hospitalization for stroke could not be detected from the present data set, although hypertension control clearly reduces stroke incidence.^30–33 The increasing fraction of stroke patients with hypertension over the 10 years may reflect either increasing stroke among older hypertensive patients or better detection of hypertension. Coding bias might also relate to the observed association. Perhaps terminally ill patients will have more severe acute conditions or complications recorded to the exclusion of less urgent chronic diseases. This is possible because the NHDS permits the recording of only 6 comorbidities.³⁴

National hospital discharge records permit the monitoring of morbidity as well as in-hospital mortality. The strength of this database includes its large size and the fact that it represents the entire US population. However, hospital discharge surveys lack clinical detail regarding treatment and course. Moreover, in this analysis, hospitalization rates were determined by combining 2 data sets. Both were national samples but involved different sampling weights. Although the different sampling weights were accounted for in the 2 data sets in this analysis, it is still possible that the calculated hospitalization rates were inaccurate. This should not affect the internal accuracy of this study, however. In addition, despite the quality control of NHDS,¹⁸ there may well have been some mistakenly coded stroke patients included in this analysis.^35,36 Nevertheless, NHDS may be particularly useful for monitoring stroke morbidity. Since stroke is a serious but not usually immediately fatal condition, hospitalization provides one potential useful view of stroke incidence and mortality patterns.

In summary, these national data suggest an evolving dissociation between trends in morbidity and mortality. The disappointing failure to detect a decline in hospitalization is balanced by a decline in hospital case fatality, as well as declining total person-days in hospital. The implication of these findings in the context of an aging population is that the burden of stroke disease is unlikely to decrease in coming decades. For nearly 30 years, preventive efforts have been largely based on reduction of blood pressure, yet since hypertension control rates seem to have stabilized, our current national strategy may not be adequate in the face of what threatens to be a growing burden of increasing stroke disease.

	Acknowledgments

 
This study was supported by a research grant from Bristol-Myers-Squibb Company. We thank Drs Robert Kaplan and Hillel Cohen for helpful comments. NHDS data were provided by the National Center for Health Statistics.

Received March 9, 2001; revision received June 26, 2001; accepted July 3, 2001.

	References

Top Abstract Introduction Subjects and Methods Results Discussion References Are We Winning the... References

 

1. Wolf PA, Cobb JL, D’Agostino RB. Epidemiology of stroke.In: Barnett HJ, Stein BM, Mohair JP, Yatsu FM, eds. Stroke: Pathophysiology, Diagnosis, and Management. New York, NY: Churchill Livingstone; 1992: 3–27.
2. Thom TJ, Epstein FH. Heart disease, cancer, and stroke mortality trends and their interrelations: an international perspective. Circulation. 1994; 90: 574–582.[Abstract/Free Full Text]
3. Lanska DJ, Peterson PM. Geographic variation in the decline of stroke mortality in the United States. Stroke. 1995; 26: 1159–1165.[Abstract/Free Full Text]
4. Cooper R, Sempos C, Hsieh SC, Kovar MG. Slowdown in the decline of stroke mortality in the United States, 1978–1986. Stroke. 1990; 21: 1274–1279.[Abstract/Free Full Text]
5. Broderick JP, Phillips SJ, Whisnant JP, O’Fallon WM, Bergstralh EJ. Incidence rate of stroke in the eighties: the end of the decline of stroke? Stroke. 1989; 20: 577–582.[Abstract/Free Full Text]
6. McGovern PG, Burke GL, Sprafka JM, Xue S, Folsom AR, Blackburn H. Trends in mortality, morbidity, and risk factor levels for stroke from 1960 through 1990: the Minnesota Heart Survey. JAMA. 1992; 268: 753–759.[Abstract]
7. Gillum RF. Cerebrovascular disease morbidity in the United States, 1970–1983: age, sex, region, and vascular surgery. Stroke. 1986; 17: 656–661.[Abstract/Free Full Text]
8. Howard G, Craven TE, Sanders L, Evans GW. Relationship of hospitalized stroke rate and in-hospital mortality to the decline in US stroke mortality. Neuroepidemiology. 1991; 10: 251–259.[Medline] [Order article via Infotrieve]
9. Terent A. Increasing incidence of stroke among Swedish women. Stroke. 1988; 19: 598–603.[Abstract/Free Full Text]
10. Haberman S, Capildeo R, Rose FC. The changing mortality of cerebrovascular disease. Q J Med. 1978; 47: 71–88.[Abstract/Free Full Text]
11. Wolf PA, D’Agostino RB, O’Neal MA, Sytkowski P, Kase CS, Belanger AJ, Kannel WB. Secular trends in stroke incidence and mortality: the Framingham Study. Stroke. 1992; 23: 1551–1555.[Abstract/Free Full Text]
12. McGovern PG, Shahar E, Sprafka JM, Pankow JS. The role of stroke attack rate and case fatality in the decline of stroke mortality: the Minnesota Heart Survey. Ann Epidemiol. 1993; 3: 483–487.[Medline] [Order article via Infotrieve]
13. McGovern PG, Pankow JS, Burke GL, Shahar E, Sprafka JM, Folsom AR, Blackburn H. Trends in survival of hospitalized stroke patients between 1970 and 1985: the Minnesota Heart Survey. Stroke. 1993; 24: 1640–1648.[Abstract/Free Full Text]
14. Graves EJ. Utilization of short-stay hospitals: United States, 1985. Hyattsville, Md: National Center for Health Statistics. Vital Health Stat 13 (91); 1987. DHHS publication (PHS) 87-1752.
15. Pokras R, Kozak IJ, McCarthy E, Graves EJ. Trends in hospital utilization: United States, 1965–86. Hyattsville, Md: National Center for Health Statistics. Vital Health Stat 13 (101); 1989. DHHS publication (PHS) 89-1762.
16. Graves EJ, Owings MF. 1995 Summary: National Hospital Discharge Survey: Advance Data From Vital and Health Statistics: No. 291. Hyattsville, Md: National Center for Health Statistics; 1997.
17. Kozak IJ. Underreporting of race in the National Hospital Dis-charge Survey: advance data of the National Center for Health Statistics: Nos. 261–270. Hyattsville Md: National Center for Health Statistics. Vital Health Stat 16 (27); 1996. DHHS publication (PHS) 96-1886.
18. Dennison C, Pokras R. Design and operation of the National Hospital Discharge Survey: 1988 redesign. Vital Health Stat 1 (39);. 2000.
19. US Department of Labor, US Department of Commerce, US Bureau of the Census. Current Population Survey, Technical Paper 53: Design and Methodology. Washington, DC: US Dept of Labor, US Dept of Commerce, US Bureau of the Census; March 2000.
20. Anderson RN, Rosenberg HM. Age standardization of death rates: implementation of the year 2000 standard. Natl Vit Stat Rep. 1998; 47: 1–17.
21. US Bureau of the Census. Census of Population: General Population Characteristics, United States. Washington, DC: US Bureau of the Census; 1992, 1990. Publication 1990 CP-1-1.
22. Lackland DT, Bachman DL, Carter TD, Barker DL, Timms S, Kohli H. The geographic variation in stroke incidence in two areas of the southeastern Stroke Belt: the Anderson and Pee Dee Stroke Study. Stroke. 1998; 29: 2061–2068.[Abstract/Free Full Text]
23. Lanska DJ, Kryscio R. Geographic distribution of hospitalization rates, case fatality, and mortality from stroke in the United States. Neurology. 1994; 44: 1541–1550.[Abstract/Free Full Text]
24. Perry HM, Roccella EJ. Conference report on stroke mortality in the southeastern United States. Hypertension. 1998; 31: 1206–1215.[Abstract/Free Full Text]
25. Pickle LW, Mungiole M, Gillum RF. Geographic variation in stroke mortality in blacks and whites in the United States. Stroke. 1997; 28: 1639–1647.[Abstract/Free Full Text]
26. Lanska DJ. Length of hospital stay for cerebrovascular disease in the United States: professional activity study, 1963–1991. J Neurol Sci. 1994; 127: 214–220.[Medline] [Order article via Infotrieve]
27. Indredavik B, Bakke F, Solberg R, Rokseth R, Haaheim LL, Holme I. Benefit of a stroke unit: a randomized controlled trial. Stroke. 1991; 22: 1026–1031.[Abstract/Free Full Text]
28. Stroke Unit Trialists’ Collaboration. Collaborative systematic review of the randomised trials of organised inpatients (stroke unit) care after stroke. BMJ. 1997; 314: 1151–1159.[Abstract/Free Full Text]
29. Jencks SF, Williams DK, Kay TL. Assessing hospital-associated deaths from discharge data: the role of length of stay and comorbidities. JAMA. 1988; 260: 2240–2246.[Abstract]
30. Whelton PK. Declining mortality from hypertension and stroke. South Med J. 1982; 75: 33–38.[Medline] [Order article via Infotrieve]
31. Whisnant JP. The decline of stroke. Stroke. 1984; 15: 160–168.[Abstract/Free Full Text]
32. Rodgers A, MacMahon S, Gamble G, Slattery J, Sandercock P, Warlow C, for the United Kingdom Transient Ischaemic Attack Collaborative Group. Blood pressure and risk of stroke in patients with cerebrovascular disease. BMJ. 1996; 313: 147.[Free Full Text]
33. Howar G, Toole JF, Becker C, Lefkowitz DS, Truscott BL, Rose L, Evans GW. Changes in survival following stroke in five North Carolina counties observed during two different periods. Stroke. 1989; 20: 345–350.[Abstract/Free Full Text]
34. Iezzoni LI, Foley SM, Daley J, Hughes J, Fisher ES, Heeren T. Comorbidities, complications, and coding bias: does the number of diagnosis codes matter in predicting in-hospital mortality? JAMA. 1992; 267: 2197–2203.[Abstract]
35. Leibson CL Naessens JM, Brown RD, Whisnant JP. Accuracy of hospital discharge abstracts for identifying stroke. Stroke. 1994; 25: 2348–2355.[Abstract]
36. Goldstein LB. Accuracy of ICD-9-CM coding for the identification of patients with acute ischemic stroke: effect of modifier codes. Stroke. 1998; 29: 1602–1604.[Abstract/Free Full Text]

Editorial Comment

Jack V. Tu, MD, PhD, FRCPC; Guest Editor

	Are We Winning the Battle Against Stroke?

Top Abstract Introduction Subjects and Methods Results Discussion References Are We Winning the... References

 
During the past decade, we have witnessed significant advances in our ability to treat patients presenting with an acute stroke. These advances include the effectiveness of thrombolytic agents in treating ischemic stroke patients who present within 3 hours of stroke onset,¹ of aspirin in treating a broad spectrum of ischemic stroke patients,² as well as the evidence from multiple randomized controlled trials demonstrating that organized stroke care in a stroke unit leads to reductions in morbidity and mortality.³ However, physicians’ optimism regarding their ability to treat stroke patients must be tempered by the failure of many trials of new neuroprotective agents to demonstrate a difference in outcome⁴ and evidence of continued suboptimal management of important stroke risk factors such as hypertension and atrial fibrillation.^5,6 Therefore, the question remains: Are we winning the battle against stroke?

In their article, Fang and Alderman, using the National Hospital Discharge Survey, provide new data on nationwide trends in the rate of stroke hospitalization and case-fatality rates between 1988 and 1997 in the United States. Although these data are not only the barometer by which progress should be measured, they are important because they offer a broad population-based perspective on recent trends in stroke hospitalization and outcomes in the "real world" of community practice, across a large and diverse country with thousands of patients, providers, and hospitals.

Several positive findings were noted in this study, of which the decline in the in-hospital case-fatality rate from stroke was arguably the most important. The decline in case-fatality suggests that there have either been (1) general improvements in the management of acute stroke patients, (2) decreases in the severity of strokes, or (3) the detection of milder cases of stroke, secondary to greater use of neuroimaging technology, in the United States.⁷ The data sources used in this study do not permit us to determine which of these explanations is the most important, although all may have played a role. The decline in case fatality, also observed in other countries,^8,9 should be tempered by the recognition that part of the decline may have been due to the shorter lengths of stay resulting in more out-of-hospital deaths.

More sobering is the finding that stroke hospitalization rates increased 18.6% between 1988 and 1997, with the increase found largely in elderly patients aged 65 years and older. Ideally, this analysis should have been restricted to first "incident" strokes. However, it was not possible to distinguish first from recurrent strokes with these administrative databases. Nevertheless, given that other studies have shown that most strokes are first-incident strokes,¹⁰ the data suggest that the overall incidence of stroke may be increasing in the United States. Factors contributing to the rising hospitalization rates in the United States most likely include the aging of the US population, success in treating other conditions such as coronary heart disease, and suboptimal primary prevention efforts. These results demonstrate a worrisome trend that has important cost and utilization implications for an overburdened healthcare system and therefore warrants our close attention.

Overall, the data from Fang and Alderman reveal a mixed picture with regard to the state of the battle against stroke. While remarkable progress has occurred over the past decade in the field of stroke, the data suggest that now is not the time for complacency. The clinical and research communities need to continue their aggressive fight against the scourge of stroke. Progress is urgently needed across the full spectrum of stroke, from primary prevention and identification of new stroke risk factors, to acute-care management and reorganization of stroke care, and improved rehabilitation so that survivors can be more fully reintegrated into the community. It will be important to continue to monitor both the successes and failures, as the battle against stroke continues.

Dr Tu is supported by a Canada Research Chair in Health Services Research. This work was supported in part by an operating grant from the Canadian Stroke Network.

Institute for Clinical Evaluative Sciences

and Division of General Internal Medicine

Sunnybrook and Women’s College Health Sciences Centre

University of Toronto

Toronto, Ontario, Canada

	References

Top Abstract Introduction Subjects and Methods Results Discussion References Are We Winning the... References

 

1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995; 333: 1581–1587.[Abstract/Free Full Text]
2. International Stroke Trial Collaborative Group. The International Stroke Trial (1ST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. Lancet. 1997; 349: 1569–1581.[Medline] [Order article via Infotrieve]
3. Stroke Unit Trialists’ Collaboration. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. Stroke Unit Trialists’ Collaboration BMJ. 1997; 314: 1151–1159.
4. Kidwell CS, Liebeskind DS, Starkman S, Saver JL. Trends in acute ischemic stroke trials through the 20th century. Stroke. 2001; 32: 1349–1359.[Abstract/Free Full Text]
5. Qureshi AI, Suri MF, Guterman LR, Hopkins LN. Ineffective secondary prevention in survivors of cardiovascular events in the US population: report from the Third National Health and Nutrition Examination Survey. Arch Intern Med. 2001; 161: 1621–1628.[Abstract/Free Full Text]
6. Gurwitz JH, Monette J, Rochon PA, Eckler MA, Avorn J. Atrial fibrillation and stroke prevention with warfarin in the long-term care setting. Arch Intern Med. 1997; 157: 978–984.[Abstract]
7. McGovern PG, Pankow JS, Burke GL, Shahar E, Sprafka JM, Folsom AR, Blackburn H. Trends in survival of hospitalized stroke patients between 1970 and 1985. The Minnesota Heart Survey Stroke. 1993; 24: 1640–1648.
8. D’Alessandro G, Bottacchi E, Di Giovanni M, Martinazzo C, Sironi L, Lia C, Carenini L, Corso G, Gerbaz V, Polillo C, Compagnoni MP. Temporal trends of stroke in Valle d’Aosta, Italy: incidence and 30-day fatality rates. Neurol Sci. 2000; 21: 13–18.[Medline] [Order article via Infotrieve]
9. Mayo NE, Neville D, Kirkland S, Ostbye T, Mustard CA, Reeder B, Joffres M, Brauer G, Levy AR. Hospitalization and case-fatality rates for stroke in Canada from 1982 through 1991: the Canadian collaborative study group of stroke hospitalizations. Stroke. 1996; 27: 1215–1220.[Abstract/Free Full Text]
10. Williams GR, Jiang JG, Matchar DB, Samsa GP. Incidence and occurrence of total (first-ever and recurrent) stroke. Stroke. 1999; 30: 2523–2528.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. M. Glymour, M. Avendano, and L. F. Berkman Is the 'Stroke Belt' Worn From Childhood?: Risk of First Stroke and State of Residence in Childhood and Adulthood Stroke, September 1, 2007; 38(9): 2415 - 2421. [Abstract] [Full Text] [PDF]

				A. I. Qureshi, M. F. K. Suri, A. Nasar, J. F. Kirmani, M. A. Ezzeddine, A. A. Divani, and W. H. Giles Changes in Cost and Outcome Among US Patients With Stroke Hospitalized in 1990 to 1991 and Those Hospitalized in 2000 to 2001 Stroke, July 1, 2007; 38(7): 2180 - 2184. [Abstract] [Full Text] [PDF]

				G. Saposnik and M. K. Kapral Poststroke Care: Chronicles of a Neglected Battle Stroke, June 1, 2007; 38(6): 1727 - 1729. [Full Text] [PDF]

				E. Onukwugha and C. D. Mullins Racial Differences in Hospital Discharge Disposition among Stroke Patients in Maryland Med Decis Making, May 1, 2007; 27(3): 233 - 242. [Abstract] [PDF]

				N. E. Mayo, L. Nadeau, S. S. Daskalopoulou, and R. Cote The evolution of stroke in Quebec: A 15-year perspective Neurology, April 3, 2007; 68(14): 1122 - 1127. [Abstract] [Full Text] [PDF]

				W. Rosamond, K. Flegal, G. Friday, K. Furie, A. Go, K. Greenlund, N. Haase, M. Ho, V. Howard, B. Kissela, et al. Heart Disease and Stroke Statistics--2007 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation, February 6, 2007; 115(5): e69 - e171. [Full Text] [PDF]

				J. E Sullivan and L. D Hedman Effects of home-based sensory and motor amplitude electrical stimulation on arm dysfunction in chronic stroke Clinical Rehabilitation, February 1, 2007; 21(2): 142 - 150. [Abstract] [PDF]

				R. Carandang, S. Seshadri, A. Beiser, M. Kelly-Hayes, C. S. Kase, W. B. Kannel, and P. A. Wolf Trends in Incidence, Lifetime Risk, Severity, and 30-Day Mortality of Stroke Over the Past 50 Years JAMA, December 27, 2006; 296(24): 2939 - 2946. [Abstract] [Full Text] [PDF]

				J. Xie, E. Q. Wu, Z.-J. Zheng, J. B. Croft, K. J. Greenlund, G. A. Mensah, and D. R. Labarthe Impact of Stroke on Health-Related Quality of Life in the Noninstitutionalized Population in the United States Stroke, October 1, 2006; 37(10): 2567 - 2572. [Abstract] [Full Text] [PDF]

				R. Jagsi, K. A. Griffith, T. Koelling, R. Roberts, and L. J. Pierce Stroke Rates and Risk Factors in Patients Treated With Radiation Therapy for Early-Stage Breast Cancer J. Clin. Oncol., June 20, 2006; 24(18): 2779 - 2785. [Abstract] [Full Text] [PDF]

				L. B. Goldstein, R. Adams, M. J. Alberts, L. J. Appel, L. M. Brass, C. D. Bushnell, A. Culebras, T. J. DeGraba, P. B. Gorelick, J. R. Guyton, et al. Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline. Circulation, June 20, 2006; 113(24): e873 - e923. [Abstract] [Full Text] [PDF]

				L. B. Goldstein, R. Adams, M. J. Alberts, L. J. Appel, L. M. Brass, C. D. Bushnell, A. Culebras, T. J. DeGraba, P. B. Gorelick, J. R. Guyton, et al. Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline. Stroke, June 1, 2006; 37(6): 1583 - 1633. [Abstract] [Full Text] [PDF]

				Q. Yang, L. D. Botto, J. D. Erickson, R. J. Berry, C. Sambell, H. Johansen, and J.M. Friedman Improvement in Stroke Mortality in Canada and the United States, 1990 to 2002 Circulation, March 14, 2006; 113(10): 1335 - 1343. [Abstract] [Full Text] [PDF]

				H. F. McGruder, J. B. Croft, and Z.-J. Zheng Characteristics of an "Ill-Defined" Diagnosis for Stroke: Opportunities for Improvement Stroke, March 1, 2006; 37(3): 781 - 789. [Abstract] [Full Text] [PDF]

				T. Thom, N. Haase, W. Rosamond, V. J. Howard, J. Rumsfeld, T. Manolio, Z.-J. Zheng, K. Flegal, C. O'Donnell, S. Kittner, et al. Heart Disease and Stroke Statistics--2006 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation, February 14, 2006; 113(6): e85 - e151. [Full Text] [PDF]

				A. Ahmed, J. Ness, G. Howard, and W. S. Aronow Cerebrovascular Diseases as Primary Hospital Discharge Diagnoses: National Trend (1970-2000) Among Older Adults J. Gerontol. A Biol. Sci. Med. Sci., October 1, 2005; 60(10): 1328 - 1332. [Abstract] [Full Text] [PDF]

				A. H. James, C. D. Bushnell, M. G. Jamison, and E. R. Myers Incidence and Risk Factors for Stroke in Pregnancy and the Puerperium Obstet. Gynecol., September 1, 2005; 106(3): 509 - 516. [Abstract] [Full Text] [PDF]